The Aids epidemic is perhaps the greatest global challenge of our generation. It is an epidemic without precedent that is still spreading rapidly.

In November 2003, UNAIDS and World Health Organization (WHO) published our annual estimates for the spread of HIV in the world. The findings are staggering.

There were more infections than ever: five million people were infected in 2003, compared with 4.8 million the year before. There were more deaths from Aids in one year than ever: three million people died, compared with 2.75 million in 2002. Women comprise half the people living with HIV, and nearly 60% in Africa.

Yet Aids is also spreading rapidly in the most populous countries of the world. There are districts in India where over 5% of the adult population is HIV positive – and one district in India can have a population greater than Switzerland. China and Indonesia also face significant Aids epidemics.

However, this is also a time of great opportunity and momentum for the global response to Aids.

There is a momentum of political engagement, starting with US president George Bush’s State of the Union speech a year ago which culminated in the US government’s initiative on Aids.

China’s premier Wen Jiabao meeting publicly with HIV-positive people on World Aids Day and UK prime minister Tony Blair’s Call for Action provide further evidence that heads of state and other leaders across the world are now fully committed to fighting Aids.

There is growing evidence that HIV prevention can work in poor countries, particularly among young people.

There is also a momentum of hope with the greater availability of anti-retroviral therapy in developing countries, including the “3 by 5” initiative of the WHO and UNAIDS – to bring Aids treatment to three million people who need it in developing countries, by 2005 – and the announcements by the South African and Indian governments to provide treatment to their citizens.

There is a momentum of funding that is genuinely unprecedented. UNAIDS estimates that $4.7 billion was spent on Aids in 2003 in low- and middle-income countries, up by 50% from 2002. There is still much more to be done – we calculate that spending needs to double.

All of this means that for the first time in the history of Aids, we have a real chance to contain it, to make sure that our children remain HIV-free, that those infected with HIV have a longer and better life and that we support the orphans left behind by the epidemic.

The challenges ahead

The investments made over the past five years are now beginning to pay off, and will produce results thanks to the massive injection of resources that is finally taking place.

However, we should not underestimate the challenges we face collectively. The most pressing challenge is that of capacity. We need a significant increase in human and institutional resources to fight Aids in Africa. The reality is that, in the most affected countries in Africa, the capacity of the state and of the private sector is eroded.

There is a double-whammy at work. On the one hand, the demand for services is increasing tremendously because of Aids; on the other, the supply of services is going down dramatically because of the impact of Aids across a wide range of indicators, from healthcare to education and economic growth.

There is no way we can win this battle by funding only short-lived projects. We must invest significantly in institutional and management capacity, even in infrastructure.

There are further challenges. Aids has come in addition to the many economic, social, governance and security problems that much of the developing world faces, particularly sub-Saharan Africa.

None of these problems has gone away, and some have got worse because of Aids. It will not be possible to control the epidemic in Africa without an exceptional effort, requiring additional resources and targeting the response to Aids at the heart of societal development.

This implies some change in the current rules, such as public budget ceilings agreed with donors and international financial institutions. Fiscal discipline is obviously critical, but the current rules may well be an obstacle to tackling the epidemic.

Exceptions should be allowed for Aids funding above such ceilings, as happens in the case of countries in post-conflict situations. We need exceptional measures for an exceptional problem.

And there is the challenge of harmonization. With so many new resources and players in the field of Aids, coordinating efforts, harmonising procedures, and working towards the same objectives is not an academic luxury.

It is vital for the broadest impact of programmes, for good use of resources and for strong accountability. In the course of the 20 years of the Aids epidemic so far, we have learned that local leadership is key, even though it appears sometimes that action may be slowed down in the short term.

There is greater international recognition and support for the “three ones” in every country: one national Aids strategy, one Aids authority and one national Aids framework for monitoring and evaluation. The result is a collective approach that every donor and institution working in the country can buy into.

The sobering reality is that we are still only at the beginning of the Aids epidemic and its impact. We must be in this for the long haul, acting with a much greater sense of urgency than we are today – since rarely has the future depended so much on what we do right now.

Peter Piot
Dr Peter Piot is the executive director of the Joint United Nations Programme on HIV/Aids (UNAIDS).